Category Archives: Health Care

Small Steps toward an Innovation-Driven Health System

Tertium Quids, a conservative advocacy organization, has been pushing three bills in the General Assembly designed to bring more “choice and accessibility” to Virginia’s healthcare system.

The goal of the “Virginia Healthcare Basket” Initiative, the group explains, is “to support the growth of innovative business models, insurance options, and technology with an eye toward creating an exciting new healthcare track which runs parallel to the overburdened and cost-prohibitive traditional health and insurance model.”

Conceptually, Democrats don’t have much to offer healthcare than more government involvement and more redistribution of wealth. Virginia Republicans have criticized the march to government-controlled medicine but they have not provided much of an alternative. The proposals touted by Tertium Quids won’t transform Virginia healthcare markets, but they would nudge the state in the direction of more innovative, entrepreneurial, market-driven healthcare. Continue reading

More Medical Insurance Mandates on the Way

Kara Murdoch. Photo credit: The Virginia Mercury

Kara Murdock, 28, lost her right hand and forearm five years ago due to a blood clot, and she has been trying without success to get a prosthetic. Her health plan turned her down when she was covered by her parents’ insurance, and now that she’s on Medicaid under the Medicaid-expansion program, she wants to make sure that her new coverage will include prosthetic devices. So reports The Virginia Mercury in an article about proposed legislation to require all health plans operating in Virginia, including Medicaid, to cover prosthetics.

Murdock’s case is a tragic one — read the story for painful details — and I have no doubt that legislators will be moved by her plight. A bill to mandate prosthetics coverage has been forwarded to the Health Insurance reform Commission, where all new mandates must be studied before the General Asssembly can pass them.

But the argument for a mandate gets complicated. Continue reading

Virginia Hospital Profitability — How Big a Problem?

Community leaders are trying to reopen Lee Memorial Hospital, which closed in 2013.

The number of Virginia hospitals operating at a loss increased dramatically — 43% — between 2016 to 2017, according to the Virginia Hospital and Healthcare Association (VHHA). Overall, one third of Virginia’s acute-care, critical-access, children’s, psychiatric, and rehabilitation hospitals experienced negative operating margins in 2017.

The problem is most acute in Virginia’s rural areas, with 57% of hospitals classified as “rural” operating in the red, said the association in a press release issued yesterday based on data published by Virginia Health Information (VHI). In all 55 of Virginia’s 105 hospitals experienced declines in their operating margins between 2016 and 2017.

The VHHA described Medicaid expansion as “a welcome development that should strengthen the Commonwealth’s health care delivery system.” However, the latest VHI data are “a stark reminder that expansion alone isn’t sufficient to address many of the broader systemic challenges facing Virginia hospitals,” such as Medicare funding cuts, inadequate reimbursements, federal government charity care mandates, and the costs associated with expanding Medicaid.

Everyone should want Virginia to have financially healthy hospitals. It is worrisome if one third of the state’s hospitals are bleeding red. However, the picture is more complicated than presented in the VHHA press release. Maybe the association is making a legitimate point, maybe it’s not. It’s hard to say based on one year’s worth of context-free VHI data. Continue reading

Bacon Bits: Scandal, Scandal, Scandal… and Dental Care

The Old Dominion is looking a lot like the Ante-Bellum Dominion. So, how are Virginia’s political scandals playing out nationally? Not very well. Headline from the New York Post: “Virginia is for Losers.” Lead story in the Wall Street Journal: “Virginia Faces Leadership Crisis as Attorney General Apologizes for Using  Blackface.”

The PC police strike again. But there’s no let-up in the racial identity wars. A fraternity and a sorority at the University of Virginia have been criticized for holding parties in which people dressed up wearing Native American attire in one instance and sombreros and maracas in another, according to the University of Virginia’s Cavalier Daily. The Inter-Fraternity Council issued a statement condemning the attire as “prejudiced and culturally insensitive.” “The IFC condemns these actions and any others that appropriate cultures.” Continue reading

What Principles Govern Virginia’s Approach to Tobacco, Vaping, Marijuana?

What’s she smoking? Is it anybody’s business? In an era in which health care costs are socialized, it’s everybody’s business.

Well, at least General Assembly Republicans are consistent. In the words of the Richmond Times-Dispatch, the House of Delegates “snuffed out” a number of marijuana bills this week, including a proposal backed by Gov. Ralph Northam to decriminalize pot. Meanwhile, they propose tightening the vice on vaping products and raising the legal age for purchasing tobacco from 18 to 21.

Republicans, it appears, are hostile to marijuana, tobacco, and indeed the inhalation of any foreign substance into the lungs. Tobacco, we know, can cause cancer. Vaping amounts to a nicotine delivery system. Nicotine is addictive, but it’s less clear that it represents a national health emergency. Indeed, my 20-year-old son, a vaper, argues that vaping substitutes for smoking tobacco, and that nicotine poses less threat to human health than the toxic brew resulting from combusted tobacco leaf. Continue reading

Shock! More “Surprise” Medicaid Cost Expenditures

Gee, who could have foreseen this? Virginia’s Medicaid expansion will cost more than expected. From the Richmond Times-Dispatch: A hospital tax designed to pay for Medicaid expansion might not cover the expense of administering a key provision of the legislation: a work requirement for people receiving benefits.

The Senate Finance Committee was “taken aback” earlier this week, reports the T-D, to discover that Governor Ralph Northam proposed using $13 million from the General Fund to seek federal approval of a work-requirement waiver. Senate Republican leaders also “expressed surprise” at a new estimate that Medicaid expansion would cost about $85 million more in the upcoming biennium than previously estimated.  Continue reading

Republicans Endorse Autism Bill. In Other Business, They Buy Pig in Poke

Bacon as beast

Republican leaders in the House of Delegates have endorsed a bill to expand coverage for children with autism. Existing law requires health insurers to reimburse autism treatments for children between 2 and 10 years old only. The proposed law would eliminate the cap.

The expanded coverage, which would help an estimated 10,000 people, would cost the state about $237,000 in additional healthcare insurance premiums, according to the Washington Post. Neither the WaPo nor Richmond Times-Dispatch provided an estimate of how much the measure would cost all Virginians, not just state employees. Continue reading

Doctors Without (State) Borders, Coast to Coast

If taken ill traveling in New York or Texas, or any other of the 50 states, odds are you would not question the basic competence of the medical professionals who treated you there.  But consult that same doctor over Skype from within Virginia and state licensing laws might get in the way.

A bill introduced to the 2019 General Assembly, pending now in both the House and the Senate, would eliminate that basic barrier by in effect allowing Virginians to use telemedicine on a national basis, removing the requirement for a Virginia license if the physician or other provider is in good standing where he or she works.

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Mapping the Opioid Death Epidemic


This map illustrates a key point in the previous post. The localities marked in blue show increases in opioid-related deaths between 2011 and 2017, and the localities shaded red experienced a decrease. While the opioid epidemic has intensified in Virginia overall, the increase (in raw numbers) has been concentrated in Virginia’s metropolitan areas. The rural pockets of “despair” have seen the problem stabilize or even recede — except, strangely enough, in the far-flung exurbs of Washington.

I’m still trying to figure out the free Datawrapper software, and I can’t get the colors in the table to match up with those on the map. And I can’t figure out how to adjust the color for poor Richmond County (the dark blue spot on the Northern Neck), which somehow got tagged with the same color as the City of Richmond. Hopefully, I’ll get better at displaying data with future maps.

Opioid Overdose Deaths and Diseases of Despair

Data source: Virginia Department of Health. (Click for larger image.)

Everyone seems to agree that Virginia, like the rest of the nation, is in the grips of an epidemic of opioid overdoses. Virginia Department of Health (VDH) data show that the number of overdose deaths attributable to Fentanyl and/or heroin and to prescription opioids has increased from 637 in 2011 to 1,426 last year. The dominant trope in reporting and commentary on this surge is to refer to it as a “disease of despair” connected to deteriorating social and economic conditions. To add insight, VDH breaks down not only the number of overdoses by locality on its data portal, but so-called “social determinants of health” such as the percentage of children in poverty.

“On the surface, it appears to be the opioid epidemic, but where you look at the opioid epidemic or addiction in general, it’s really a disease of despair,” said State Health Commissioner M. Norman Oliver at a Virginia Board of Health meeting last month. “What drives it is the lack of jobs, the lack of affordable housing, the lack of transportation …” Continue reading

Does Virginia Do Income-Verification for Medicaid Recipients?

Just to be clear, cracking down on Medicaid fraud is not a “dog whistle” for targeting African-American welfare queens. Many if not most perpetrators of illegal schemes to collect public benefits are white, as illustrated by this cast of characters indicted last year in Lakewood, N.J. for illegally collecting Medicaid and other welfare benefits.

Last month a Louisiana state audit of 100 randomly selected Medicaid beneficiaries found that 82 did not qualify for the benefits they received. Most under-reported their income, some shamefully. Two recipients were getting Medicaid despite having incomes above $300,000.

Now, Louisiana is Louisiana, not exactly known for squeaky clean governance. But there is accumulating evidence that other states have similar problems. According to the Washington Times, a federal inspector general’s report this year found 38 out of a sample of 150 Medicaid beneficiaries in California were potentially ineligible. Continue reading

Is Autism Increasing, or Is the Diagnosis of Autism Increasing?

This chart reflects the number of children taking the SOL Reading tests. It may omit a few children who did not take the test.

The number of children with autism in Virginia public schools surged roughly 270% between the 2005-06 school year and the 2016-17 school year, far outpacing the modest increase in children with disabilities, according to data in the Virginia Department of Education SOL “Build-a-Table” database.

Most other major classifications of disabilities declined over the same period, raising the possibility that the dramatic increase in the number of children with autism reflects not an underlying increase in children with the disability but a reclassification of children already known to have learning and emotional problems. Continue reading

Medicaid Expansion’s Achilles Heel: the Doctor Shortage

Source: “Virginia Physician Workforce Shortage” presentation to the Joint Commission on Health Care, Sept. 2013.

The Northam administration sold Medicaid expansion to the public in part by claiming that the net cost to Virginia taxpayers would be minimal. Uncle Sam would pay for 90% of the cost of extending medical coverage to up to 400,000 Virginians, and the state’s 10% share would be offset by savings in prisons, mental health, and other areas. What no one talked about, except in the fine print, was the necessity of increasing reimbursements to physicians.

The Richmond Times-Dispatch editorial page explains today why higher reimbursements for physicians are an integral and unavoidable part of Medicaid expansion:

Medicaid underpays its physicians, reimbursing them at only 71 percent of the rate they get paid by Medicare, and an even smaller percentage of what private insurers pay. As a consequence, only 63 percent of physicians accept Medicaid patients, and only 71 percent of those are taking new patients. So, when Medicaid expands eligibility to as many as 400,000 near-poor Virginians this year, many will find it difficult to find a primary care physician, and they’ll wind up seeking care in the emergency room, just like they always have.

The Department of Medical Assistance Services (DMAS), which administers Virginia’s Medicaid program, now is asking for $19.1 million in the second year of the next biennial budget for Virginia’s share of the cost to lure more docs into the program. The hope is that hiking reimbursements from 71% of the Medicare benchmark to 80% of the benchmark will induce a meaningful number of physicians to take more Medicaid patients.

How likely is that?

Virginia has about 25,000 full-time-equivalent physicians, according to “Virginia Physician Workforce: 2016” published last year by the Healthcare Workforce Data Center (HWDC).

Source:  “Virginia Physician Workforce: 2016”

HWDC found that 57% of physician were accepting new patients at their primary office. Of those who are taking in more patients in their primary offices, 35% can accept no more than 50, while 23% can accept between 50 and 99 new patients. If I understand its presentation correctly (see the chart to the left) HWDC estimated a “new patient capacity” of about 14,000 at both primary and secondary locations. That’s a drop in the bucket compared to the expected influx of 400,000 new Medicaid patients.

The shortage is not likely to improve. Nearly 4,000 doctors, about 17% of the physician workforce, are over 65 years or older. Although many docs plan to work into their 70s, 8% of Virginia’s physicians plan to retire within two years, and 30% expect to do so within 10, estimates the HWDC.

If 8% of physicians retire in the next two years — about 1,000 per year — there are two ways, broadly speaking, to replace them. (1) working physicians can take in more patients, and (2) hospitals can recruit more doctors.

Female physicians work fewer hours on average than males at all ages. Source:  “Virginia Physician Workforce: 2016

While older physicians are predominantly male, the younger generation of physicians is half female. That’s great for gender equality, but it stretches the profession even thinner because female physicians tend to work fewer hours than males (presumably because, as mothers, many are juggling professional and domestic responsibilities). As male physicians age out and are replaced by females, doctors on average will tend to work fewer hours, meaning they will see fewer patients. For this and other reasons, 2,531 doctors told HWDC they were planning to decrease patient hours compared to 2,183 who said they were planning to increase their hours within the next two years — a net of 348 doctors intending to cut back.

Another way to accommodate 400,000 more Medicaid patients is to train and recruit new doctors. According to HWDC data, Virginia medical schools granted 1,322 residencies over the past five years. That’s a pipeline of barely 600 per year. Assuming every Virginia resident stayed in Virginia (which they don’t), the number fall significantly short of the 1,000 or so doctors expected to retire. That means the gap must be filled by recruiting doctors from outside the state. How likely is that to occur? Who knows. That’s a big uncertainty.

Some regions of Virginia will be able to absorb the influx of Medicaid patients better than others. The major metropolitan areas have higher doctor-population ratios than the non-metros. Indeed, as shown in the map at atop of this post, a 2013 presentation to the Joint Commission on Health Care designated much of the state as “primary care shortage areas.” That presentation cited a shortage of 126 primary care physicians in those areas. Continue reading

Va 2019 General Assembly session – prefiled House of Delegates bills

Click here to see the 9 weird laws

Much ado about nothing.  As of this morning there were 83 prefiled bills for the House of Delegates and 225 prefiled bills for the State Senate.  With a few exceptions the House prefiles are pretty “ho hum”.  I will examine the Senate prefiles in a subsequent column.

One from column A and two from column B.  I use a somewhat arbitrary approach to categorizing the prefiled bills.  By my analysis … governmental process (17), education (12), crime and courts (10), election reform (8), finance and taxes (7), health care (6), nonsense (6), environment (6), transportation (4), campaign reform (4) and energy (2).

Governmental process.  These are the day to day clarifications, corrections and amplifications needed to make existing legislation more effective.  For example, HB246 clarifies the role of the code commission in preparing legislation at the direction of the General Assembly.  One of these bills will further depress Jim Bacon’s journalistic sensibilities.  HB1629 eliminates the requirement that Virginia procurement contracts be reported in newspapers.  Mixed in with the proposed routine legislation are some zingers.  For example, there are three separate bills to ratify the Equal Rights Amendment (HJ577, HJ579, HJ583).  There are also four bills proposing changes  to the Virginia Constitution.  HJ578 would add a right to vote to the state constitution, HJ582 would establish a redistricting committee, HJ584 would allow the governor to run for a second consecutive term and HJ585 has the governor and lieutenant governor running as a single ticket instead of separate offices.

Education.  The only theme in the education prefiles is an attempt to provide financial incentives for localities to rebuild the physical plant of their schools.  One of the more interesting bills would allow commercial advertising on school buses (HB809) while another would guarantee that our children’s God given right to wear unscented sun block not be abridged (HB330).

Crime and courts.  Bail bondsmen and bondswomen are forbidden from having sex with their clients (HB525) and shooting a police dog, or even showing a gun to a police dog,  becomes a more serious crime (HB1616).  Other than that, pretty mundane stuff.

Finance and taxes.  Way too many people and too many companies are paying taxes (HB966) and veterinarians really need a break from those pesky sales taxes (HB747).

Potpourri.  The remaining categories contain a few interesting ideas.  Del Rasoul wants to ban the use of fossil fuels in electricity generation (HB1635), Del Cole wants to give I95 some love (HJ580, HJ581) and he also has the radical idea that campaign contributions should not be for personal use (HB1617).  In fact, Del Cole’s proposed legislation is putting him perilously close to making my very short list of competent Virginia legislators.

Closer to home.  My delegate, Kathleen Murphy, continues to propose jaw dropping, eye popping examples of legislative uselessness.  She proposes to let her pals skirt Virginia traffic laws by displaying a special sticker on their cars (HB295) and offers some odd rules on distance learning reciprocity (HB659).  I guess issues like mass transportation don’t cross her mind these days.

— Don Rippert.

Medicaid Is The Story With State Budget

New hospital taxes collected from Virginia private hospitals in this budget cycle, and the federal matching Medicaid dollars they draw down. The larger portion covers higher payment rates, not coverage of new patients.

The General Assembly’s key money committees gathered in their annual end-of-year financial retreats last week to talk about Medicaid.  Sure, the state’s multi-billion-dollar budget delves into plenty of other areas that were mentioned, and the Amazon location announcement grabbed headlines, but the meetings were about Medicaid.

The explosive and uncontrolled growth of Medicaid is all but eliminating any new dollars for those other areas of state responsibility, and existing dollars are under pressure.  There is no point in talking about anything else.  The opportunity for tax reform due to windfall revenue may be short-circuited by Medicaid.  If the rosy projections of new state money from Amazon come to pass, every dollar may be needed for Medicaid.

Every year the Joint Legislative Audit and Review Commission (JLARC) does this dry report about the growth in state spending.  The simple bottom-line fact it has demonstrated over and over is that Medicaid is squeezing everything else out.  It looks back at a ten-year period and during the ten years leading up to and including 2017, 60 percent of all General Fund growth went to for Medicaid.

JLARC: 60 percent of the growth in state spending over ten years has gone to Medicaid (Department of Medical Assistance Services). The was before the 2018 expansion.

At the beginning of the period the state’s allocation to localities for public schools was the top expenditure, but it dropped down to second by Fiscal Year 2017.   During that same ten-year period, from FY 2008 through 2017, the Department of Education didn’t even make the list of the ten agencies with the highest growth in General Fund dollars.

Right behind Medicaid’s 60 percent of the new money over the decade was the Treasury Board (debt payments) and the Department of Behavioral Health and Developmental Services, the other state agency providing major direct medical services to citizens.  A similar chart from the 2009 report, looking at 2000-2009, had Medicaid getting 19 percent of the growth revenue, and the Department of Education 39 percent.  A healthy share of growth dollars going to education may never happen again.

Medicaid (DMAS) and Department of Education have switched places on JLARC’s latest report on state spending. This includes state and federal shares.

The figures in the JLARC report, of course, do not include the impact of the expansion of the program to an estimated 375,000 more recipients by July 2020.  Nor do they include the $463 million in cost overruns announced since the budget was adopted (several months late, remember) in the existing pre-expansion program.  Those will not show up in a JLARC look-back report until the 2020 report on Fiscal Year 2019.

That would be after the next election.

The state’s economy is improving and an additional $600 million or more in tax dollars are expected this year and next, the committee staffs reported, but about 75 percent of those new dollar will be needed for that overrun.

Continue reading